Chapter 20: Documenting the Intervention Plan

Introduction

The Intervention Plan portion of the note is the final part of the Plan of Care (P). It describes the plan for the patient interventions, or the forms of treatment the patient will receive over the course of skilled therapy to achieve the anticipated goals/short term goals established in the initial evaluation.

Relationship to Anticipated Goals

Once the Anticipated Goals/Short Term Goals are set, an Intervention Plan is then set up as a summary of the forms of treatment the therapist plans to utilize over the course of treatment to achieve the patient's goals and improve the patient's functional status. A single exercise or intervention may help the therapist work with the patient to achieve more than one Anticipated Goal. In fact, it is advantageous and economically sound to establish an Intervention Plan to achieve the goals most efficiently. When setting up an Intervention Plan, several factors must be considered:

• Each anticipated goal

• The patient's allotted time for therapy

• The patient's exercise tolerance level

• The patient's level of motivation to participate with therapy and improve his current functional status

• The patient's support system

Information Included in the Intervention Plan

Just as certain information is required for documentation of the examination to be complete, the following information must be included in the Intervention Plan section of a note:

• Type of therapy setting in which the patient will be seen (e.g., acute care inpatient physical therapy, home health speech therapy, outpatient occupational therapy)

• Frequency that the patient will be seen by the therapist over the course of treatment (e.g., 2x/day or 3x/wk)

• Anticipated length of time that the patient will be seen over the full course of therapy services (e.g., for 6 wks; or until discharged from hospital)

• Location of the treatment (e.g., at bedside, in the therapy department, in outpatient aquatic center, at home)

• The interventions that the patient will receive in detail and the planned progression for these interventions. (The amount of specificity may depend on the setting. See the following for more detail on describing interventions. For the purposes of this textbook, a significant level of detail is expected, but this detailed information will be provided for you.)

• Anticipated discharge location

• Plans for further examination or re-examination

• Any referrals made to other services (e.g., nutrition consult; referral to a specialist, such as an orthopedic physician or dentist, for further evaluation; referral to a different rehabilitation professional, e.g., to a speech therapist to assess swallowing)

The following are also frequently included in the Intervention Plan section of the initial evaluation note:

• Patient and family education (e.g., home exercise program; if provided, attach a copy of any home exercise program[s] [signed and dated, of course] to the health record)

• Any equipment for which the patient and/or his caregiver has been educated

• Any equipment recommended ...